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Independent review of the circumstances surrounding four serious adverse
incidents that occurred in the Oncology Day Beds Unit, Bristol Royal
Hospital for Children on Wednesday, 3 January 2007
Jonathan Sheffield
Medical Director
All HUMAN BEINGS ARE
PRONE TO MAKING
INADVERTANT ERRORS
Heparin.
Summary: incidents aetiology
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The security status of the Controlled Drugs Cabinet in which the CPA’s
drugs were stored appears to have been cognitively down graded from
high security to a safe place to keep things.
CPA was in a rush to start the List. He had not been able to have a rest
break and had recently been given some distressing news.
CPA was not aware that monoparin was stored in the CDC.
CPA had seen the drug that he intended to use to keep the patients
intravenous catheters and cannula patent (Hepsal) unboxed in the CDC
on previous occasions.
CPA did not read the labels on the ampoules of monoparin correctly, i.e.
he saw what he expected to see rather than perceiving the information
that was physically present.
CPA undertook the preparation of the drugs for all four patients in one
batch thus creating the potential for a systemic failure which then
occurred.
CPA did not carry out a verbal double-checking safety protocol because
he was not aware that the Trusts Medicines Code required him to
undertake one before the administration of medicines to children.
Comparison outer packaging monoparin and Hepsal
Comparison monoparin and Hepsal ampoules respectively
Hepsal and monoparin ampoules respectively
The incident
• What, when, how and who?
• Site visit
• Decision
Families
• How
• Why
• Future
Why independent?
• Objectivity
• Open
• Change
Previous knowledge
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Human beings are prone to making inadvertent errors and especially when
working conditions are less than optimum
It is well known that look-alike drug labels have led to patients being harmed
inadvertently by healthcare professionals
Patients prescribed ‘heparin flushes’ have on numerous occasions been
inadvertently administered significant overdoses of heparin e.g. USA
September 2006
Latest incident - USA 21 November 2007, Denis Quaid twins plus two other
neonates 1000 times more heparin than intended
Verbal double safety checks can reduce the risk of an error being made e.g.
radiotherapy, IVF or airline pilots cross checks
Batch working can lead to systemic failures
Trust outcome
• Go to action plan